Provider Demographics
NPI:1750483699
Name:CLARK, RAYMOND H (MD)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:H
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10705
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-0012
Mailing Address - Country:US
Mailing Address - Phone:501-472-7697
Mailing Address - Fax:501-336-8837
Practice Address - Street 1:5330 PLANTATION CV
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-8586
Practice Address - Country:US
Practice Address - Phone:501-472-7697
Practice Address - Fax:501-336-8837
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC82362084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR129952001Medicaid
AR5K251Medicare ID - Type Unspecified
F83916Medicare UPIN
AR129952001Medicaid